Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Manhattan Community Care Center during CMS and state inspections, most recent first.
Inadequate clean linens were available on the second floor, affecting a resident’s bed and the linen supply for the unit. A resident representative was changing linens and found no pillowcases available, and later a resident was observed without a top sheet, lying on a fitted sheet under a bedspread. A CNA confirmed there were no linens available in the linen closet and said it was not unusual for the closet to be empty. The DON acknowledged ongoing issues with maintaining clean linens, and the Laundry Supervisor and Administrator confirmed laundry staff were responsible for stocking the clean linen closets.
Call Light Not Within Reach: A resident's call light was observed placed under the bed and behind the headboard, out of reach while the resident was in bed. Facility policy stated the call system must be accessible to residents in their bed or other sleeping accommodations, and CNA, DON, and Administrator interviews confirmed call lights were expected to remain within reach. The resident had multiple diagnoses, including stroke-related dysphagia, DM, gastrostomy status, heart disease, a sacral pressure ulcer, and prostate cancer, and was assessed as severely cognitively impaired and dependent for all ADLs.
Failure to follow wound care plan: A resident with stage 4 pressure ulcers to the sacrum and left lower leg had dressings left in place beyond the ordered daily change schedule. The care plan directed daily cleansing, Santyl, and dressing changes, but the TAR had no wound care documentation for one day, and the DON confirmed wound care was not provided despite adequate nursing coverage. The resident had severe cognitive impairment, hemiplegia/hemiparesis after CVA, and was dependent for all ADLs.
Failure to provide ordered daily wound care for a resident with a stage 4 sacral pressure ulcer and additional stage 4 wounds to the L ankle and L calf. The resident had severe cognitive impairment, was dependent for all ADLs, and had physician orders for daily dressing changes and Santyl to the sacrum. During observation, an LPN confirmed the dressings had been applied the prior day, but TAR review showed no wound care documentation for one day, and the DON confirmed the care was not provided as ordered despite available nursing staff.
The facility failed to follow its abuse prevention policy by not removing a CNA from resident care after multiple abuse allegations, and did not conduct a timely or thorough investigation. Two residents with significant medical and cognitive needs reported rough and intimidating treatment by the CNA, but the CNA continued to provide care to them. Nursing staff acknowledged the complaints but did not ensure the CNA was reassigned, and family members were not updated on the investigation.
A resident with dementia and a history of exit-seeking behaviors was assisted outside by staff without proper identification or supervision, resulting in the resident being unsupervised outdoors for an extended period and later found lying on the ground near the facility's perimeter. The staff member responsible had not verified the resident's identity or risk status, and the incident was not immediately recognized by the assigned unit manager, leading to a lapse in required supervision and security.
A resident with a non-pressure ulcer did not receive wound care as ordered by the physician, with a scheduled treatment missed and not documented. Staff interviews revealed confusion regarding the wound care schedule, and the dressing change was not properly signed, dated, or timed. The DON and Administrator confirmed the lapse in care.
A resident with severe cognitive impairment and a care plan requiring one-on-one supervision was left unsupervised, resulting in a fall and a fracture. The resident exhibited agitation during a therapy session, but the speech therapist did not inform the nursing staff, assuming they were monitoring the resident. The assigned CNA was late, and no other staff was designated to supervise, leading to the resident's injury.
A resident with dementia and behavioral disturbances fell and sustained a fracture due to a lapse in supervision at an LTC facility. The resident was supposed to be under continuous one-on-one supervision, but the assigned CNA arrived late, leaving the resident unsupervised. The resident was agitated and attempted to stand during a therapy session, and later fell in the dayroom, resulting in hospitalization.
Two residents in the facility reported deficiencies in accommodating their preferences for hydration and personal care. One resident, with severe cognitive impairment, preferred daily shaving and bedside water, but these preferences were not met, leading to delays and the resident's representative having to assist with shaving. Another resident, who is cognitively intact, also experienced delays in receiving water and preferred having it readily available at the bedside. The acting Administrator acknowledged the expectation to accommodate resident preferences.
A facility failed to respect a resident's food preferences, leading to a deficiency. Despite the resident's clear dislike for oatmeal and her cognitive ability to communicate this, she continued to receive it on her breakfast tray multiple times weekly. The facility's policy required that food preferences be recorded and utilized, but this was not followed. The dietician and acting Administrator were aware of the issue, yet the resident's preferences were not accommodated.
A facility failed to maintain sanitary practices in food service when a Registered Dietitian (RD) was observed picking up an ink pen from the floor and handling food service items without washing her hands. The RD also licked her fingers while flipping through meal cards. Interviews with the RD, Dietary Manager (DM), and Assistant Administrator (AA) confirmed these actions, despite annual infection control training.
The facility was found to have unlocked biohazard rooms on two survey days, with open biohazard cans and chemical dispensers inside. The Housekeeping Supervisor and ANHA acknowledged the need for these doors to be locked to ensure safety.
The facility failed to implement comprehensive care plans for several residents, leading to unmet needs. A resident requiring adaptive utensils for self-feeding was not consistently provided with them, while others lacked engagement in scheduled activities. Additionally, a resident's comprehensive care plan was overdue, and another's skin care interventions were not followed. Staff interviews confirmed these deficiencies.
A CNA improperly applied zinc oxide cream, considered a medication, to a resident's buttocks and perineal area, contrary to facility policy which mandates that only licensed personnel administer medications. The CNA was unaware that zinc oxide was a medication and applied it after each incontinent episode, as observed by surveyors. The DON confirmed the policy breach, stating CNAs should only use barrier cream.
The facility failed to provide adequate activities for residents, particularly on the upper floors, leading to a lack of engagement and dissatisfaction among residents. Observations showed residents were often left without activities, despite scheduled events on the activity calendar. Staff and resident interviews confirmed that activities were primarily conducted on lower floors, leaving some residents without appropriate engagement.
A resident with an indwelling suprapubic catheter was observed with catheter tubing dragging on the floor, posing an infection control issue. The tubing's contact with the floor was confirmed by an LPN and acknowledged by the DON and Assistant Executive Director as a significant infection risk. The resident had a history of HIV and Neuromuscular Dysfunction of the Bladder.
A facility failed to provide a palatable meal during a lunch observation, as a resident and the Dietary Manager noted the macaroni and cheese was bland and lacked flavor. The resident, who is on a Regular, NAS diet with diabetes precautions, expressed that the food often lacked taste. The facility's policy requires meals to be nourishing and palatable, which was not met in this instance.
A resident with a hand disability was not consistently provided with a built-up fork, as required by their care plan, leading to challenges during meals. Despite the facility's policy and the resident's repeated requests, the necessary utensil was often missing from meal trays. Staff acknowledged the shortage of built-up forks and had placed an order, but delays contributed to the ongoing issue.
The facility failed to ensure call light accessibility for two residents, impacting their ability to request assistance. One resident with Hemiplegia and Cerebellar Stroke Syndrome was unable to reach the call light placed behind her, while another resident with Major Depressive Disorder and Osteoarthritis had the call light hung out of reach. The DON and Administrator acknowledged the importance of call light accessibility, although no specific policy was in place.
The facility failed to implement comprehensive care plans for two residents, resulting in deficiencies in care. One resident's call light was out of reach, preventing assistance with urinary incontinence and fall prevention. Another resident's call light was also out of reach, and their bed was left elevated, contrary to care plan instructions. Staff confirmed the importance of following care plans to meet residents' needs.
A resident with incontinence did not receive timely and proper incontinence care, as required by facility policy. The resident was left without care for several hours, and when care was provided, a CNA used improper techniques by wiping back to front with the same cloth, increasing the risk of infection. Despite in-service training, the facility's documentation did not accurately reflect the timing of care provided.
Inadequate Clean Linens on the Second Floor
Penalty
Summary
The facility failed to provide adequate bed linens to maintain a comfortable, homelike environment on the second floor. Record review showed the facility policy for Laundry and Linen was intended to provide a process for the safe and aseptic handling, washing, and storage of linen. During observation, the resident representative for one resident was changing the linens on the resident’s bed and there were no pillowcases available on the second floor. The resident representative stated that she had experienced a lack of clean linens for the resident several times in the past. At another observation, a resident was found lying on a fitted sheet under a bedspread with no top sheet on the bed. A CNA confirmed the resident had no top sheet because none were available and stated it was not unusual for the linen closet to be empty of clean linens. Observation of the second-floor linen closet showed there were no clean pillowcases, fitted or flat sheets, towels, or washcloths available. The DON acknowledged issues with maintaining clean linens in the clean linen closet, and the Laundry Supervisor stated emergency linen had not been put out as expected. The Administrator confirmed it was the responsibility of laundry staff to ensure adequate clean linens were delivered to the clean linen closets on each floor. The residents involved had significant care needs, including dependence on staff for all ADLs and functional abilities, and diagnoses including dysphagia, stroke-related conditions, diabetes, gastrostomy status, heart disease, pressure ulcer of the sacral region, hypertension, and prostate cancer.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure a call light was within reach for one of six residents sampled, Resident #2. The facility policy titled, CALL LIGHT/CALL PAGER SYSTEMS, stated that the call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room. During observation on 5/11/26 at 12:40 PM, Resident #2's call light was found placed under the bed and brought up and over the headboard, with the call button positioned behind the headboard and out of the resident's reach. Interview with CNA #2 on 5/11/26 at 2:00 PM indicated that each resident was to have the call light in reach to summon assistance as needed. Resident #2's record showed admission diagnoses including dysphagia following cerebral infarction (stroke), diabetes mellitus, gastrostomy status, heart disease, pressure ulcer of the sacral region, and malignant neoplasm of the prostate. The annual MDS with ARD 3/27/26 assessed the resident as severely cognitively impaired for daily decision making, with memory problems, and dependent for all ADLs and functional abilities. The DON and Administrator both stated they expected call lights to be left within reach of residents and answered in a timely manner.
Failure to Follow Wound Care Plan
Penalty
Summary
The facility failed to implement the comprehensive, person-centered care plan for a resident with a stage 4 pressure ulcer to the sacrum and a stage 4 pressure ulcer to the left lower leg. The care plan directed staff to cleanse the sacral wound with normal saline, pat dry, apply Santyl, and cover with a dry dressing daily, and to cleanse the left lateral leg wound with normal saline, pat dry, apply Santyl, cover with calcium alginate, and secure with a dry dressing daily. On observation, the resident had wound dressings on the sacrum, left lateral calf, and left ankle dated 5/09/26, and the LPN confirmed she had applied those dressings on 5/09/26 and that the care plan required daily dressing changes. After the dressings were removed, the NP stated the sacral wound appeared to have more slough than it usually did when it was changed every day according to the care plan. Record review of the TAR for May 2026 showed no documentation of wound care on 5/10/26. The DON confirmed there were adequate licensed nurses on duty that day, including two wound care nurses and an RN Supervisor, and agreed that wound care was not provided on 5/10/26 based on the dated dressings and lack of TAR documentation. The resident was admitted on 4/01/26 with diagnoses including dysphagia, hemiplegia and hemiparesis following cerebral infarction, and stage 4 pressure ulcer of the sacral region. The 5 Day MDS showed a BIMS score of 7, indicating severe cognitive impairment, impairment of both arms and legs, and dependence for all ADLs.
Failure to Provide Ordered Daily Wound Care
Penalty
Summary
The facility failed to ensure ordered wound treatments were administered as prescribed for one resident with existing skin impairments. The resident was admitted with diagnoses including dysphagia, hemiplegia and hemiparesis following cerebral infarction, and a stage 4 pressure ulcer of the sacral region. The resident’s MDS showed severe cognitive impairment with a BIMS score of 7, impairment of both upper and lower extremities, and dependence for all activities of daily living. Physician orders in the order summary required daily treatment for a stage 4 left lateral ankle wound, a stage 4 left lateral calf wound, and daily Santyl ointment to the sacrum. During observation, wound dressings were found on the sacrum, left lateral calf, and left ankle, and the LPN confirmed she had applied those dressings on the prior day. The LPN also confirmed the physician orders required the dressings to be changed daily. After the dressings were removed, the NP stated the sacral wound appeared to have more slough than usual when it was changed every day. Review of the TAR for May 2026 showed no documentation of wound care for one day, and the DON confirmed that wound care was not provided on that day despite adequate licensed nursing staff being on duty, including wound care nurses and an RN supervisor. The DON and Administrator both stated they expected wound care nurses to monitor the TARs and provide wound care as ordered by the physician and care plan.
Failure to Remove CNA and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its abuse prevention policy by not removing a Certified Nursing Assistant (CNA) from resident care following multiple allegations of potential abuse. Despite reports from residents and their family members that the CNA was rough, mean, and had allegedly hit or intimidated a resident, the CNA continued to provide care to the same residents. Interviews revealed that both residents and their representatives reported these concerns to nursing staff, but the CNA was not removed from their assignments, and continued to enter the rooms of the affected residents. The investigation into the allegations was neither timely nor complete. Family members and residents reported that after making complaints to the nursing staff, there was no follow-up or communication from the facility regarding the status of the investigation or any actions taken. The LPN Charge Nurse acknowledged her responsibility to remove the CNA from resident care during an allegation of abuse, but confirmed that the CNA continued to have contact with the residents involved. The Director of Nursing (DON) also indicated that the situation should have been addressed more thoroughly, especially since multiple residents had raised concerns about the same CNA. The residents involved had significant medical conditions and cognitive impairments, as indicated by their diagnoses and Brief Interview Mental Scores (BIMS). One resident expressed fear and distress due to the CNA's continued presence, stating she could not sleep while the CNA was in the room. Documentation and interviews confirmed that the facility did not implement interventions to protect residents from further potential abuse, nor did it ensure proper reporting and investigation procedures were followed as outlined in its abuse prevention policy.
Failure to Prevent Elopement Due to Inadequate Supervision and Staff Error
Penalty
Summary
A newly admitted respite resident with diagnoses of restlessness, agitation, dementia, senile degeneration of the brain, and a history of exit-seeking behaviors and falls was assisted to exit the facility by staff. The resident was outside unsupervised for approximately twenty-five minutes until a staff member observed her lying on the ground next to the iron fence that encircled the facility premises, about 375 feet from the facility entrance. The resident had been admitted earlier that day and was only oriented to self, with a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The facility's policy required staff to know the location of their residents and to report or intervene if a resident attempted to leave the premises. However, the receptionist, who was not aware of the new admission and had not verified the resident's identity, unlocked the door and escorted the resident outside without determining if she was safe to exit. The resident then wandered the grounds unsupervised, eventually being found by staff who were leaving their shift. The staff who found her did not initially recognize her as a resident and had to ask questions to confirm her status before summoning the DON and assisting her back into the facility. Interviews and record reviews confirmed that the receptionist had received training on security and elopement risks but failed to follow procedures. The incident was not immediately recognized by the assigned unit manager, who had assessed the resident as not at risk for elopement based on incomplete information. The resident's responsible party and primary healthcare provider were notified after the incident, and the resident was not injured. The facility's failure to provide adequate supervision and a secure environment contributed to the resident's elopement and placed all residents with wandering or exit-seeking behaviors at risk.
Removal Plan
- A second at risk for elopement assessment completed for Resident #9
- Resident #9's Instant care plan and Kardex were updated
- One-on-one supervision orders received, and monitoring implemented
- Resident #9's Responsible Party (RP) and Primary Healthcare Provider were notified of the incident with safe wandering device bracelet orders received with bracelet applied on Resident #9 with orders for nurses to check placement and functioning every shift
- Head to toe body audit was conducted for Resident #9
- Nursing staff completed 100% head count of all residents not signed out on pass with all residents accounted for
- Employee corrective counseling completed with former Receptionist (Category 1 offence, employment terminated)
- 100% At risk for elopement evaluations completed on all residents
- 100% in-service training started for all staff prior to working on - Elopement/Wandering, Abuse/Neglect, Behaviors, Adequate monitoring, Supervision
- Safe wandering devices for all residents wearing them are checked every shift for placement and functioning
- Elopement Drills were conducted on all shifts
- 100% audit of elopement books completed
- All doors checked for proper functioning
- Security specialist contractor visited and checked doors for functioning
- Quality Assurance (QA) Meeting attended by all key personnel, which included but not limited to Executive Director, Director of Nurses, Infection Preventionist and Medical Director was held with root cause analysis conducted and interdisciplinary team developed strategy to prevent future elopement incidents
- Resident #9 to remain on 1:1 until discharge from facility; discharged
- Resident photos will be taken at the time of admission, regardless of elopement risk assessment results, and posted at the receptionist desk
- One-on-one monitoring/supervision of Resident #9 through discharge
- Admissions Coordinator to monitor the communication board in the reception office to ensure the board's accuracy and currently with all new admissions' photographs posted
- Continued elopement assessments of all newly admitted residents at the time of admission by nursing staff
- Continued monitoring of positioning and functioning of safe wandering devices worn by residents at risk of elopement every shift by nursing staff
- Continued daily monitoring of the safe wandering system functionality by the maintenance director
- Review of and development of care plans for all newly admitted residents with family/resident to evaluate for history of wandering/elopement for three (3) months with monitoring results and corrective actions reviewed at QA meetings for three (3) months
Failure to Provide Wound Care per Physician Orders and Facility Policy
Penalty
Summary
The facility failed to provide wound care in accordance with physician orders and facility policy for one resident with a non-pressure ulcer. The resident had a physician order for wound care to be performed every three days, including cleaning the wound with normal saline, applying Mupirocin ointment, and covering with Mepilex. Documentation showed that wound care was completed on one scheduled date but was not documented or performed on the next scheduled date, as evidenced by the absence of staff initials in the treatment record. The resident reported that the wound care was not performed as ordered and that the wound was not irrigated as specified in the physician's instructions. Interviews with staff revealed a lack of awareness and adherence to the wound care schedule. The LPN/unit manager stated that a PRN order had been obtained and that she provided the dressing change a day after it was missed, but the dressing was not signed, dated, or timed as required. Another LPN was unaware of why the wound care was missed, and the DON and Administrator acknowledged that the care had not been completed as ordered. The resident had a history of diabetes, a non-pressure chronic ulcer, and vascular dementia, with intact cognition at the time of the incident.
Failure to Implement Care Plan Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to implement a care plan intervention for a severely cognitively impaired resident, resulting in an unsupervised fall and an acute transverse fracture of the lower sacrum. The resident, who was admitted with diagnoses including dementia with behavioral disturbances and osteoarthritis, had a comprehensive care plan requiring one-on-one supervision when family was not present. On the day of the incident, the resident was left unsupervised in the dayroom after a therapy session, despite exhibiting agitation and attempts to stand up. The speech therapist, who had been working with the resident, did not notify the nursing staff of the resident's behavior before leaving, assuming they were observing him through a window. The Director of Nursing acknowledged that the resident was supposed to have one-on-one supervision, but the assigned CNA was late, and no other staff was designated to monitor the resident. Consequently, the resident was found sitting on the floor in the dayroom, having fallen and later diagnosed with a fracture. Interviews with staff, including the DON and MDS Coordinator, highlighted the importance of following the care plan to ensure resident safety, which was not adhered to in this case, leading to the resident's injury.
Lapse in Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents, resulting in a fall and injury to a resident. The resident, who had been admitted with dementia and behavioral disturbances, was supposed to be under continuous one-on-one supervision due to increased agitation. However, there was a lapse in supervision when the assigned CNA did not arrive on time, and no other staff member was present to supervise the resident. On the day of the incident, the resident was observed to be agitated and attempting to stand up during a therapy session. The therapist redirected the resident but did not inform other staff of the resident's behavior, assuming they were being monitored. After the therapy session, the resident was left unsupervised in the dayroom, where they eventually fell and sustained a fracture. Interviews with staff revealed that there was a miscommunication regarding the supervision assignment. The CNA who was supposed to provide one-on-one supervision arrived late, and the LPN on duty was unaware that the resident was left unsupervised. The Director of Nursing confirmed that there was a lapse in supervision, which led to the resident's fall and subsequent hospitalization.
Failure to Accommodate Resident Preferences for Hydration and Personal Care
Penalty
Summary
The facility failed to accommodate resident preferences for two residents, leading to a deficiency in promoting and facilitating resident self-determination. Resident #4, who has severe cognitive impairment due to Parkinson's Disease and Alzheimer's Disease, expressed a preference for having water available at the bedside and being shaved daily. However, the facility only provided water upon request, causing delays, and did not accommodate the resident's preference for daily shaving, leaving the resident's representative to sometimes perform the task during visits. Similarly, Resident #3, who is cognitively intact and has diagnoses including Congestive Heart Failure, Type 2 Diabetes Mellitus, and Hypertension, also reported not having water readily available at the bedside. The resident stated that requests for water often resulted in waiting periods, and she preferred to have a water pitcher, glass, or bottle at her bedside. The acting Administrator confirmed that staff are expected to accommodate resident preferences, but this was not achieved in these cases.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to provide a diet according to a resident's preferences, resulting in a deficiency. A resident, who was admitted with diagnoses including End Stage Renal Disease, Dependence on Renal Dialysis, and Type 2 Diabetes Mellitus, expressed dissatisfaction with receiving oatmeal on her breakfast tray multiple times weekly, despite her dislike for it. The resident, who was cognitively intact with a BIMS score of 15, had communicated her food preferences to the staff multiple times. The facility's policy required that resident food preferences be recorded and consistently utilized, but this was not adhered to in the case of this resident. The facility's dietician acknowledged awareness of the resident's complaints about oatmeal and had emphasized the importance of accommodating food preferences to the dietary staff and cooks. The acting Administrator also confirmed the expectation that dietary staff should accommodate resident food preferences whenever possible. Despite these acknowledgments, the resident continued to receive oatmeal, indicating a failure in the facility's processes to ensure dietary preferences were respected.
Failure to Maintain Sanitary Practices in Food Service
Penalty
Summary
The facility failed to maintain sanitary practices in accordance with professional standards for food service safety, specifically related to hand hygiene. During an observation, a Registered Dietitian (RD) was seen picking up an ink pen from the kitchen floor and placing it back on the steam table. Subsequently, the RD handled a food service utensil, a food thermometer, and a menu book without washing her hands. Additionally, the RD was observed licking her fingers while flipping through residents' meal cards, which were to be placed on each tray. Interviews with the RD, Dietary Manager (DM), and Assistant Administrator (AA) confirmed these observations. The RD acknowledged the actions and admitted that she would not want her food contaminated in such a manner. The DM confirmed witnessing the RD's actions and stated that staff were expected to use hand hygiene in the kitchen, with annual training provided on infection control. The AA also acknowledged the incidents and emphasized the expectation for staff to follow safety protocols and use hand hygiene after touching contaminated surfaces.
Unlocked Biohazard Rooms Compromise Safety
Penalty
Summary
The facility failed to provide a safe environment for residents, as evidenced by unlocked biohazard rooms on two of the four days of the survey. On 07/22/24, an observation revealed an unlocked door marked 'Biohazard' on the second floor, with an open red biohazard can and visible red biohazard bags inside. Additionally, housekeeping chemical dispensers containing Vindicator, a disinfectant with health hazards for acute oral toxicity and skin corrosion/irritation, and Super Shine All, a floor cleaner with health hazards for serious eye damage/eye irritation, were present. On 07/23/24, during an observation and interview, the Housekeeping and Laundry Supervisor confirmed the biohazard room door was not secured and stated that such doors should always be closed and locked to ensure safety. The Assistant Nursing Home Administrator acknowledged the requirement for biohazard room doors to be closed and locked, emphasizing the responsibility of all employees to secure these doors to prevent exposure to medical waste or chemicals.
Deficiencies in Care Plan Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for six of the thirty sampled residents, leading to deficiencies in meeting the residents' needs. For Resident #53, the care plan indicated the need for adaptive equipment, specifically built-up utensils for self-feeding due to a hand disability. However, observations revealed that the resident was not consistently provided with the necessary utensils, forcing him to eat with his hands. Despite repeated requests to the kitchen staff and CNAs, the resident often did not receive the appropriate fork, highlighting a failure in adhering to the care plan. Resident #57's care plan required staff to remind and encourage participation in group activities, but observations showed a lack of individualized activities and engagement for residents on the third floor, including Resident #57. Similarly, Resident #121 and Resident #122, who also resided on the third floor, were not provided with appropriate activities as outlined in their care plans. The facility's activity calendar indicated scheduled activities, but none were observed during the survey period, indicating a failure to implement the care plans effectively. Resident #68's care plan was incomplete, as the comprehensive care plan had not been developed despite the resident's admission date being well past the timeframe for completion. Additionally, Resident #80's care plan required specific skin care interventions, but there was a lack of adherence to the care plan regarding the application of zinc oxide for skin impairments. Interviews with facility staff, including the LPN, RN, AED, and DON, confirmed the deficiencies in care plan implementation and the importance of following care plans to ensure appropriate care for residents.
Improper Medication Administration by CNA
Penalty
Summary
The facility failed to adhere to professional standards by allowing a Certified Nursing Assistant (CNA) to apply a medicated cream, zinc oxide, to a resident's buttocks and perineal area, which is against the facility's policy. The policy specifies that medications should only be administered by licensed personnel. The incident involved a resident who was alert and oriented, and who reported discomfort in her buttocks. The CNA applied the zinc oxide cream after each incontinent episode, believing it was a barrier cream, not realizing it was considered a medication. The deficiency was observed during a survey when a jar of zinc oxide was found on the resident's bedside table. The CNA confirmed applying the cream, stating she was instructed to do so after every incontinent episode. The Licensed Practical Nurse (LPN) and the Director of Nursing (DON) acknowledged that the CNAs were not authorized to apply zinc oxide, which should only be applied by licensed nurses. The DON admitted to being unaware that CNAs were using zinc oxide instead of the barrier cream provided by the facility.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide activities of interest to meet the needs of three residents, as observed during a survey. Resident #57, who had severe cognitive impairment, was frequently found sleeping in a Geri chair or in the hallway with no activities provided, despite the activity calendar indicating scheduled events like Bingo and Coffee. The resident expressed that there was nothing to do, and staff confirmed that activities were primarily conducted on the lower floors, leaving residents like #57 without engagement. Resident #121, with severe cognitive impairment, was observed talking to a baby doll and ambulating the hallways without any individualized activities. The resident's MDS indicated a preference for music, group activities, and outings, none of which were provided. Observations showed the resident was often left without appropriate engagement, contributing to a lack of stimulation and potential behavioral issues. Resident #122, who was cognitively intact, expressed dissatisfaction with the lack of activities and the inability to go outside. The resident was observed wandering the hallways and was difficult to redirect, as confirmed by staff. The activity calendar listed various activities that were not conducted, and interviews with staff and the Resident Council President revealed systemic issues with staffing and scheduling, leading to insufficient activity provision on the upper floors.
Failure to Prevent Infection Control Issue with Catheter Tubing
Penalty
Summary
The facility failed to prevent potential complications related to a resident with an indwelling suprapubic catheter. During an observation, it was noted that the catheter tubing of Resident #117 was dragging on the floor as the resident moved through the dining room and hallway in a wheelchair. This observation was confirmed by a Licensed Practical Nurse (LPN) who acknowledged that the tubing's contact with the floor posed an infection control issue. The resident had a physician's order for a 16F 10cc suprapubic Foley catheter with a closed urinary drainage bag system, dated April 3, 2024. Interviews with the Director of Nursing (DON) and the Assistant Executive Director further confirmed the deficiency. Both acknowledged that indwelling catheters could be a significant cause of infection, and it was the responsibility of the nursing staff to ensure catheter tubing was not in contact with the floor. The resident, admitted on October 20, 2023, had diagnoses including Human Immunodeficiency Virus (HIV) disease and Neuromuscular Dysfunction of the Bladder, and the Quarterly Minimum Data Set (MDS) assessment dated June 28, 2024, confirmed the presence of an indwelling catheter.
Deficiency in Meal Palatability
Penalty
Summary
The facility failed to provide a palatable meal during a lunch observation, as evidenced by the State Agency (SA) and the Dietary Manager (DM) sampling a lunch tray that included macaroni and cheese, which was found to be bland and lacking cheese flavor. This observation was corroborated by Resident #14, who expressed that the food often lacked taste, specifically noting the tastelessness of the macaroni and cheese served at lunch. The facility's policy on Menu Planning and Requirements, dated 2016, mandates that meals should be nourishing, palatable, and attractive, which was not adhered to in this instance. Resident #14, who was admitted to the facility on 11/22/23, has a diagnosis of Type 2 Diabetes Mellitus and is on a Regular, No Added Salt (NAS) diet with diabetes precautions. The resident's cognitive status is intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 on the Quarterly Minimum Data Set (MDS) assessment dated 05/03/24. The Assistant Executive Director (AED) emphasized the expectation for the Dietary Manager to prepare flavorful and safe meals, highlighting a discrepancy between expectations and the observed meal quality.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to consistently provide adaptive eating equipment to a resident who required it due to a hand disability. The resident, who was cognitively intact and diagnosed with paraplegia, needed a built-up fork to eat independently. Despite the facility's policy stating that adaptive devices should be available to residents at mealtime according to their individualized plan of care, the resident frequently did not receive the necessary utensil. Observations during mealtime confirmed that the resident's tray often lacked the built-up fork, forcing him to eat with his hands, which he found challenging and frustrating. Interviews with the resident, dietary staff, and a CNA revealed that the issue was ongoing and known to the staff. The Dietary Manager and Assistant Administrator acknowledged that the facility was running low on built-up forks and had placed an order for more, but the delay in receiving them contributed to the deficiency. The resident had repeatedly requested the appropriate utensil, and it was noted on his meal ticket, yet the staff often failed to provide it. This lack of consistent provision of adaptive equipment led to the resident's dissatisfaction and difficulty during meals.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that residents had access to their call lights, which are essential for communication and requesting assistance. This deficiency was observed in two residents. Resident #4, who was admitted with diagnoses including Hemiplegia following Cerebral Infarction and Cerebellar Stroke Syndrome, was found in her room with the call light placed on a nightstand behind her, out of reach. Despite needing assistance with incontinence care, she was unable to reach the call light. A family member and the facility Ombudsman had previously expressed concerns about the resident's inability to access the call light, which was confirmed by a Certified Nurse Aide (CNA) during an interview. Similarly, Resident #5, who has been diagnosed with Major Depressive Disorder and Osteoarthritis, was observed sitting in a wheelchair with the call light hung over a wall-mounted light fixture, making it inaccessible. The resident confirmed the inability to reach the call light. The Director of Nurses acknowledged the importance of call light accessibility and stated it was the staff's responsibility to ensure call lights were within reach. The facility Administrator expressed surprise at the situation and confirmed that staff were expected to make rounds to check call light placement, although there was no specific policy in place regarding call light accessibility.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in their care. For Resident #5, the care plan identified the need to keep the call light within reach to assist with urinary incontinence and prevent falls due to right lower leg pain and a history of falls. However, an observation revealed that the call light was placed out of reach, hanging over a wall-mounted light fixture on the opposite side of the room. This oversight prevented the resident from calling for assistance, as required by the care plan. Similarly, Resident #4's care plan included measures to prevent urinary tract infections and falls, such as keeping the call light within reach and ensuring the bed was in the lowest position. Observations and interviews revealed that the call light was out of reach, and the resident was unable to call for assistance with incontinence care. Additionally, after providing care, CNAs left the resident's bed elevated, contrary to the care plan's instructions. Interviews with staff, including the DON and the Administrator, confirmed the importance of adhering to care plans to meet residents' needs, highlighting the facility's failure to do so in these instances.
Inadequate Incontinence Care Leading to Potential Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident who was always incontinent of bowel and bladder, as documented in the 5 Day Minimum Data Set. On the day of observation, the resident was left without incontinence care from 10:30 AM until 1:35 PM, despite the facility's policy requiring care every two hours and as needed. During the care provided at 1:40 PM, a CNA used improper techniques by wiping back to front multiple times with the same side of a disposable cleansing cloth, which contradicts the facility's policy of wiping front to back with a clean area of the cloth for each stroke to prevent urinary tract infections. Interviews with the CNAs and the Director of Nursing confirmed that the facility provided in-service training on proper incontinence care procedures, which were not followed in this instance. The documentation entered into the facility's system did not accurately reflect the timing of care provided, as it showed only one episode of care before 11:00 AM, despite the resident being observed without care for several hours. The facility's administrator confirmed the expectation for CNAs to adhere to the proper procedures to prevent infections.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alyce G Clarke Center For Medically Fragile Childr | 1.1 mi | — | 0 | 0 |
| Lakeland Community Care Center | 1.3 mi | ★★★★★ | 5 | 0 |
| Pine Forest Health And Rehabilitation | 2.5 mi | ★★★★★ | 6 | 0 |
| Compere Nh Inc | 3.3 mi | ★★★★★ | 0 | 0 |
| Highland Home | 4.5 mi | ★★★★★ | 1 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.